Outline

In developmental cataract there is more at issue than opacification of the lens only. The anterior vitreo-lenticular interface plays an important role in the surgical approach which is particularly important when using the bag-in-the-lens technique. All babies and children operated at our department for congenital cataract are treated by using this technique [1], [2] because of its reduced rate of visual axis reproliferation. However, this technique requires not only an anterior capsulorhexis but also a posterior capsulorhexis, and this independently of the presence of a persistant hyperplastic primary vitreous (PHPV) or persistant fetal vasculature (PFV). In reviewing the surgical video’s, the relation between the anterior hyaloid and the posterior capsule, which defines the space of Berger, shows a large variety of anatomical particularities. This new observation, triggered our curiosity and motivated us to better understand the “anterior interface”. While all efforts are currently focused on the vitreo-retinal interface, we now focus on the vitreo-capsular interface. In case of congenital dysgenesis of the anterior interface (which corresponds to remnants of the fetal vascular capsule), the proliferative tissue is removed either from the posterior capsule or from the anterior hyaloid, in an attempt to reduce the need for an anterior vitrectomy to a minimum. Bridges between the anterior hyaloid and posterior capsule can easily be ruptured by ocular viscoelastic dissection. Vitreocapsular bridges are the most commonly observed particularities of the anterior interface which can be found at any age, even in adults.

Better knowledge of this anterior vitreo-lenticular interface can improve significantly the surgical outcome of children with developmental cataract and the more, reduce the postoperative complications. We currently lack medical devices allowing us to visualize this anterior interface prior to surgery. The clinical aspect of a congenital cataract only does not disclose preoperatively all anomalies of this anterior interface. The pediatric cataract surgeon should however, always keep these kind of peroperative surprises into account. Dissection of the primary vitreous from the posterior capsule is time-consuming but feasible. Chemicals such as microplasmin may be of some help for the cataract surgeon to optimize the separation of the anterior hyaloid or the fetal vascular proliferative membrane from the posterior capsule.

It is evident that developmental cataract involves more ocular pathologies than the lens only. However, there is much hope that cataract surgery in babies and children will give more satisfactory refractive results than it is currently the case, provided the surgical approach, the intraocular lens design and the IOL calculation are optimized.